WI0100151_Regional Office Physical File Scan Up To 9/22/2022

PermitNumber W1010015
OR 19 2ui1
Program Category
Asheville Regional Office
Ground Water
Permit Type
Injection Water. Only GSHP Well System (50W)
Primary Reviewer
michael.rogers
Coastal SW Rule
Permitted Flow
Facility
Central Files: APS SWP
04/14/11
rmit Tracking Slip
Status
Project Type
bctive
New Project
Version
Permit Classification
1.00
Individual
Permit Contact Affiliation
Von Plemmons
PO Box 71
Hot Springs NC 28743
'Facility Name Major/Minor Region
Frank & Julia Bonomo SFR Minor ishevill
Location Address County
96 Waynewood Dr Haywood
Waynesville NC 28786 Facility Contact Affiliation
Owner
Owner Name
Owner Type
Individual
Frank Bonomo
Owner Affiliation
Frank Bonomo
96 Waynewood Dr
Dates/Events
Waynesville NC 28786
Scheduled
Orig Issue App Received Draft Initiated Issuance
Public Notice Issue Effective Expiration
04/14/11 04/13/11
04/14/11 04/14/11
Rewulated Activities
Heat Pump Injection .
Outtall NU L L
Waterbody Name Stream Index Number Current Class Subbasin

A 7k hL
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue CQleen H. Sullins
Governor Director
4/ 14/2011
Frank Bonomo
Julia Bonomo
96 W aynewood Drive
Waynesville, NC 28786
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well System
Permit No. WIO100151
96 Waynewood Drive, Waynesville, NC 28786
Dear Alr. & Airs. Bonomo:
Dee Freeman
Secretary
On 4/13/2011, the Aquifer Protection Section (APS) received notification of your intent to construct a closed -loop water -only
geothermal injection well system for the operation of a ground -source heat pump located at the address referenced above. An
individual permit is not required for the construction and operation of this type of geothermal injection well system as long as the
following conditions are.met:
1., The injection well system contains only potable water,
•2. The injection well system is constructed in accordance with well construction standards specified in North
- Carolina Administrative, Code Title 15A Section 2C Subchapter .0213, and
3. The required notification form and associated maps have been completely and accurately submitted.
Failure to comply with all of these conditions constitutes a violation of the North Carolina Well Construction Act and North Carolina
Administrative Code Title 15A Section 2C Subchapter .0211(u)(2). Additionally, you should contact the Haywood County Health
Department as they may have additional requirements for this type of system. Noncompliance with applicable state, county, or
municipal rules and regulations may result in the assessment of civil penalties.
Please contact Mike Rogers at [phone] or Michael.Ro2ers0),ncdenr.gov if you have any questions.
Sincerely,
Q) wzck'
/orDcbra Watts
Supervisor
cc: Asheville Regional Office - APS
APS Central Files - Permit No. W10100151
Haywood County Health Dept.
Clearwater Well Drilling, Inc (Von Plemmons)
Gentry Heating, Inc. (Duane Gentry)
AQUIFER PROTECTION SECTION
1636 Nail Service Center, Raleigh, North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigh, North Carolina 27604
Phone: [phone] FAX 1: 919-715-0588; FAX 2: 919-715-60481 Customer Service: 1-877-623-6748
Internet: www.ncwateraualitV.org
An Equal Opportunity 1 Affirmative Action Employer
One.
NorthCa.1-oh.im
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NORTH CAROLINA
DF.PARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM
TYPE 50W WELLS)
In Accordance With the Provisions of NCAC Title 15A 02C.0200
Print or type the required information, and mail to address on the back page.
45 n
DATE: - - g `a 20� �,' `, O � 36 `r J
Well Type Confirmation: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed -loop)?
Yes " Continue completing this form.
No Do Not complete this form. Complete other UIC application forms for installing
either a 5A7 well (open -loop well injecting potable water into the aquifer) or a 5QM well (closed -
loop well containing additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
A. PROPERTY OWNERS)/APPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, state name of
entity and a representative w/authority for signature): 4-)- G 0 v-% N3 0
(1) Mailing Address: --
City: U.�Gt..v _ate �l (-C State: f`CZip Code: County:
Home/Office TeleZ� 2� -- CUU Cell No.:
1, �
Email Address�f)k')noVI 02-1 roe- Website•
(2) Physical Address of Well Site (if different than above):
City: State: Zip Code: County:
Home/Office Tele No.: Cell No.:
B. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate UIC well)
Company Name:
Contact Person: EMAIL Address:
Address:
City: State: Zip Code: County:
Office Tele No.: Cell No.: RECEIVED / DENR ni i , f
Aau ler Protection SecfiQ;
Website Address of Company, if any:
APR IS 2011
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008) Page 1

C.
01
E.
F.
WELL DRILL
Company Nam
Well Driller Ct
NC Contractor
Contact Person
Address: T
City: 51C)"_tM$ S Zip Code
Office Tele No.: -
7�13 County: !V�(S tM
Cell No.: US V_)24 _ 7 nt,,
HEAT PUMP CONTRACTOR INFORMATION (if different than driller)
Company Name: 0(? 6`h4 �-Mqi (tq 1t .
Contact
E-
Address: up-atou-4 E. ,kCi ss y d
City: S,,.Uc!(,hQO Zip Code: 4"M county: �hC�`v✓lla�
Office Tele No.: S2�-2.Jq -n2_0 Cell No.: sz, 5-5S2 I `i Z- t
STATUS OF APPLICANT
Private: V Federal:
State:
Municipal:
Commercial:
Native American Lands:
INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
lmcd Loa.yjc*�r 6Cud&--6 ON, -
G. WELL CONSTRUCTION DATA
(1) Proposed date to be constructed: �{" 2gI 2 0� Number of borings:
Approximate depth of each boring (feet): 200
(2) Type of tubing to be used (copper, PVC, etc): RPC_ - `4Q%
(3) Well casing. Is the well(s) cased? (check either (a.) Yes or (b.) No below)
(a) Yes if yes, then provide casing information below
Type: _galvanized steel black steel plastic other (specify)
Casing depth: From to feet (reference to land surface)
Casing extends to above ground inches
(b) No f
(4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement Bentonite
(b) Grout placement: Pumping Pressure
(c) Grout depth of tubing (reference to land surface): from
If well has casing, indicate grout depth: from _
Other (specify) 5aA1d
Other
to (feet)
to (feet)
(n O&A
GPU/U1C 5QW Notification of Intent Form (Revised 8/2008) page 2

H. INJECTION -RELATED EQUIPMENT
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
piping/tubing associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
I. LOCATION OF WELL(S)
Attach two copies of maps showing the following information:
(1) Include a Site Map (can be drawn) showing: buildings, property lines, surface water bodies, potential
sources of groundwater contamination and the orientation of and distances between the proposed well(s) and
any existing well(s) or waste disposal facilities such as septic tanks or drain fields located within 200 feet of
the geothermal heat pump well system. Label all features clearly and include a north arrow.
(2) The Site Map must show the subject property in relation to the surrounding area by using at least two fixed
reference points such as roads, streams, and/or highway intersections. .
J. CERTIFICATION
Note: This Permit. Application must be signed by each person appearing on the
recorded legal property deed.
"I hereby certify, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and complete.
I am aware that there are significant penalties, including the possibility "of fines and imprisonment, for submitting
false information. I agree to construct, operate maintain, repair, and if applicable, abandon the injection well and
all related appurtenances -in accordance with t approjue4pepications and,/Fonditions of the Permit."
Ti�ature of Property Owne��plicant
Print or Type Full Name and title
Sig ture of Propa Owner/Applicant
Print or Type Full Name and title
Signature of Authorized Agent, if any
Print or Type Full Name and title
Please return two copies of the completed Application package to:
North Carolina DENR-DWQ
Aquifer Protection Section-UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636 RECEIVED 1 pENR ! GV�C"
Telephone [phone] Aquifer Prote:^tion Section,
APR IS . 2011
GPU/UIC 5QW Notification of Intent Form (Revised 8/2008) Page 3

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